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J Thorac Cardiovasc Surg 1995;109:190-191
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Imaging of traumatic rupture of the aorta

Elvis Presley Trauma Center
Department of Surgery
University of Tennessee
Memphis, TN 38163

To the Editor:

In their letter titled "Transesophageal Echocardiography for the Diagnosis of Traumatic Injury of the Thoracic Aorta" (J THORAC CARDIOVASC SURG 1994;107:638-40), Hengster, Furtwangler, and Pernthaler) allege that transesophageal echocardiography (TEE) "has never been reported to be used after accident in a traumatized patient." In March 1991, a publication from the Mayo Clinic reported a case of traumatic rupture of the aorta diagnosed by TEE. ¹ In June of 1991, the Allegheny General Hospital group published a series of 58 patients with chest trauma evaluated over 10 years in which the modality was used, with traumatic rupture of the aorta being demonstrated in three patients. ² In 1993, the University of Kentucky reported seven cases of traumatic rupture of the aorta among their 69 patients with trauma studied by this technique. ³ In early 1993, two similar instances were reported from Paris, France. ⁴ In 1991, we instituted a (blinded) study of TEE in patients with trauma and, since the reports of the experience of the Pittsburgh and Lexington teams, have used it routinely.

More important than the issue of priority are the conclusions, based on a single patient, that TEE is "highly sensitive and specific" and avoids "invasive and time-consuming investigations." In our experience with the modality (along with aortography) in more than 50 patients with suspected traumatic rupture of the aorta, TEE has been useful in the diagnosis of this injury. However, the lesion was missed by TEE in two patients in whom traumatic rupture of the aorta was demonstrated by aortogram and confirmed by operation. In both patients, the aortogram was performed first and had demonstrated the transection. Despite intense efforts by experienced observers, the injury could not be visualized by means of TEE.

Because of the reasons mentioned in the authors' letter, TEE is a useful modality in patients with trauma. It is an adjunct but cannot completely supplant aortography. Our early experiences with helical or spiral computed tomographic studies are impressive, but we must remember that computed tomography itself was originally considered highly sensitive until tragic experiences taught otherwise. A high index of suspicion in an experienced clinician remains the key requirement for timely diagnosis. All techniques have limitations, and those of TEE have not been completely delineated. It is a highly operator-dependent modality with a significant learning curve. Its place in the diagnosis of traumatic rupture of the aorta is yet to be defined.

References

1. Locke TJ, Reeder GS, Khandheria BJ, McGregor CGA. Diagnosis of traumatic aortic rupture by transesophageal echocardiography. J Thorac Cardiovasc Surg 1991;101:555-6.[Medline]
   
2. Brooks SW, Cmolik B, Young JC, et al. The use of transesophageal echocardiography in the evaluation of chest trauma. J Trauma 1991;32:761-6.
   
3. Kearney PA, Smith DW, Johnson SB, Barker DE, Smith MD, Sapin PM. Use of transesophageal echocardiography in the evaluation of traumatic aortic injury. J Trauma 1993;34:696-701.[Medline]
   
4. Goarin JP, LeBret F, Riou B, Jacquens Y, Viars P. Early diagnosis of traumatic thoracic aortic rupture by transesophageal echocardiography. Chest 1993;103:618-20.
   

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James W. Pate Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pate, J. W. Articles by Minard, G. Search for Related Content PubMed PubMed Citation Articles by Pate, J. W. Articles by Minard, G.